New Polytrauma System of Care Yields Tremendous Hope

Odette A. Harris MD, MPH, FAANSoh
Department of Neurosurgery Stanford University Medical Center

Director, Defense Veterans Brain Injury Center
Stanford, CA

Advancement of medical knowledge has often occurred during and after wars. For neurosurgery, the Civil War brought an understanding of peripheral nerve injuries and infection prevention, while World War I enabled a clearer understanding of penetrating head injuries. Operations in the Middle East — Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) — resulted in significant knowledge of medical and rehabilitation care of the traumatic brain injury (TBI)/polytrauma injured patient. The U.S. Department of Veterans Affairs (VA) has also elevated its own medical readiness, accountability to service and responsibility toward its stakeholders.

The delivery of rehabilitation care to veterans with TBI and associated trauma has gone through a significant transformation since our country’s involvement in OEF and OIF. In 2005, the VA developed a memorandum of agreement with the U.S. Department of Defense (DoD) to care for and rehabilitate active duty service members injured in theater and non-combat accidents. A Polytrauma System of Care (PSC) within the VA was created, assigning five sites throughout the United States as centers of comprehensive care for these patients. This program incorporated a cadre of specialized clinicians and services (including neurosurgeons) in an integrated, interdisciplinary infrastructure that leveraged geographically established resources and networks to ensure a continuum of care for injured service members.


2016 marked the tenth anniversary of the initiation of this effort. Over this last decade, thousands of military service members with injuries ranging from mild to catastrophic have been treated. Included were women and men with, various levels and combinations of TBI, multi-limb amputation, visual impairment, post-traumatic psychological conditions and other associated disorders. The result of this national effort has been far reaching, with the progressive development of an integrated system of rehabilitation that affords improved coordinated care for patients as a whole. The resulting advancements in medical and rehabilitation delivery have been remarkable, and the potential for further landmark improvements and innovations in facilitating recovery in all rehabilitation patients is now deemed limitless. It is essential that the attention to, and resource allocation toward, this effort be sustained to continue this progress.

milNotable breakthroughs in TBI/polytrauma care of the injured patient are highlighted below:

  • TBI and Visual Disorders. There has been significant knowledge gained regarding TBI and concomitant visual disorders sustained by post blast injuries. The work of Cockerham and Goodrich revealed significant occult visual conditions that otherwise has gone undetected. This work resulted in the prestigious Olin Teague Award.
  • Emerging Consciousness. Severely brain-injured patients who would previously die despite aggressive acute resuscitative efforts are now surviving and subsequently admitted into the PSC’s as emerging consciousness (coma) patients. The organized interdisciplinary efforts of the rehabilitation team allowed further research directed toward understanding and impacting the outcome of these patients. Codified management algorithms and nuances in approach to clinical and pharmacologic management of these patients developed, which increased the probability of patients emerging from a coma. More improvement in cognitive recovery than previously obtained in this population was also achieved. Additional sustained attention and care to these TBI patients afforded much better prognosis with improved chances of emerging from a coma.
  • Women and Brain Injury. With the enlisting of more women during this conflict, a better understanding of the effects of brain injury and other associated trauma on women has also been gained and will hopefully enable more specifically target rehabilitation efforts.
  • Reintegration. As part of the rehabilitation process, more efforts during these years have appropriately given high priority to facilitating the patient’s reintegration back into society and family. Progress has already been attained, and additional efforts continue.

These contributions are staggering and meaningful. Neurosurgeons have worked to advance and achieve these results. Ongoing success requires continued attention and designated resources toward providing this level of care. This will ensure the level of readiness and attention to duty that is expected of it from the citizens and governing bodies of the United States.

Editor’s Note: We encourage everyone to join the conversation online by using the hashtag #ConcussionFacts.

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Equestrian Traumatic Brain Injury – Opportunities to Acknowledge, Educate and Guide

ann-hsAnn R. Stroink, MD, FAANS
Central Illinois Neuro Health Science
Bloomington, IL

The fall season soon approaches with exhilarating thoughts of crisp air, bonfires and outdoor sports! It is also the season when the media will focus on concussions in professional football players. This draws attention to the potential hazards of football, with needed public reminders about traumatic brain injury (TBI) and prevention. This is particularly poignant as parents sign up over 1.2 million American youths for tackle football this year.

Receiving much less attention are the competitive and non-competitive equestrian athletes of the horse sports industry which account for more sports-related TBIs than football and other sports. In 2009, 14,446 emergency room visits were attributed to equestrian brain injuries in riders with 26.3 percent requiring hospital admission. This past spring, a ten-year retrospective analysis from the National Sample Program of the National Trauma Data Bank on adult (>18 years of age) sports-related TBIs, published in Neurosurgical Focus, revealed key information. Data indicated that equestrian sports were the largest contributor to sports-related TBI in adults accounting for 45.2 percent of all brain injuries, followed distantly by contact sports (20.35), roller sports (19%), skiing/snowboarding (12%) and aquatic sports (3.5%).

The turnout for the carriage, the horses and harness and for the whip and passengers is strict according to the type of driving event being undertaken. While competition driving requires modern lightweight carriages for fast maneuvering around obstacles and helmet and body protection for participants, pleasure driving, on the other hand, such as the invitational Big Bend Drive through the Brandywine Valley to the Winterthur Point-to-Point Races, as shown in the photo, requires antique or traditional style carriages and formal dress with stylish hats, rather than helmets that would distract from the historical integrity expected from the event.

The turnout for the carriage, the horses and harness and for the whip and passengers is strict according to the type of driving event being undertaken. While competition driving requires modern lightweight carriages for fast maneuvering around obstacles and helmet and body protection for participants, pleasure driving, on the other hand, such as the invitational Big Bend Drive through the Brandywine Valley to the Winterthur Point-to-Point Races, as shown in the photo, requires antique or traditional style carriages and formal dress with stylish hats, rather than helmets that would distract from the historical integrity expected from the event.

In the United States alone, approximately 30 million Americans ride horses each year for both recreational and competitive sports. Equestrian athletes, particularly prone to TBIs, ride competitively in events that vary both in the types of competitions and geographic locations of where these events typically occur — as many horse sports activities are tied to local customs, culture and tradition. The recent summer Olympic Games in Rio drew attention to the equine disciplines of dressage, eventing, show jumping and driving, which represents only a small slice of the horse sport industry. Equestrian sport covers a broad spectrum of horse related activities not only for equine athletes but also for the providers who care for these animals. Equestrian competition encompasses a vast sports industry in horse-specific racing, English and Western riding, rodeo and stock handling, driving in harness as well as team sports like polo and horseball.

The horse adds a significant dimension to the complexity of the injury risk. Although these animals are highly trained and disciplined, their behavior can be unpredictable to the rider. Other factors that also contribute to higher rates of injuries associated with equine activities include:

  • Rider experience;
  • Body posture;
  • Riding surface;
  • Environmental variations;
  • Weather conditions; and
  • Equipment failure.

While there is little concussions or head injury risk difference between Western and English style riding, the risk does increase when the competitions involve polo, horse racing and eventing. Current estimations indicate that 75-80 percent of head injuries occur while the rider is seated on the horse. Sadly, there remain head injuries that also occur during the care and maintenance of horses during:

  • Veterinarian checks;
  • Stall cleaning;
  • Feeding;
  • Grooming; and
  • Farrier care.

Spectators have also been injured from runaways, close but not vigilant observation and an unpredictable horse. Whether athletes are mounted in competition or unmounted in driving or preparing a horse for events, they are still at risk for TBIs.

helmetGiven these statistics, what can be done? Helmets, like in other sports, seem one important step so why is there still debate regarding these at equestrian competitions? Currently, in the U.S., less than one in eight riders use helmets. New York and Florida have passed legislation that requires helmets to be worn by riders under the age of 16 while the remainder of states have remained silent on this initiative. Organizations overseeing polo and horse racing do require helmets for riders. The United States Equestrian Federation mandates helmets on mounted riders anywhere on the showgrounds and requires the helmets be ASTM International (ASTM) certified. The ASTM establishes criteria for horseback riding helmets that is universally recognized in the U.S. horse industry. In the world of Western horse competition, helmets are not required in most events, although some participants and venues have recently adopted voluntary use. The aversion to embracing the safety requirements set up by other horse organizations is driven by the tradition of wearing a conventional style of hat worn by peers, such as cowboy hats in western venues, fedoras or bowlers in English. This then stands in the way of safety. For others, it’s the perceived discomfort in wearing a riding helmet and not getting the shade offered by the brim of the conventional hat.

Concussions remain the leading cause of disability for equestrians. A recent study reported in Sports Health concluded that equestrian athletes were misinformed and unaware of the potential negative consequences of concussions and timing for return to competition as a result of receiving little, if any, education in head injuries. This is despite all the attention given to concussions in other sports and the media.

The science of helmets offering protection for the athlete is evident, but not accepted by all equine sport activities, and the evidence is clear that equestrian TBIs far outweigh in frequency any other sport-related head injuries — including football. It’s prime time to put more effort into addressing the deficiencies in safety for our equestrians. Neurosurgery will continue to lead the way to emphasize, educate and guide the media and the equestrian sport industry to promote awareness for head injury prevention in this large vulnerable group.

Editor’s Note: We encourage everyone to join the conversation online by using the hashtag #ConcussionFacts.

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Achieving Greatness: #ConcussionFacts

hsChristine Hammer, MD, Neurosurgery Resident, Thomas Jefferson University (left)
Analiz Rodriguez, MD, PhD, Neurosurgical Oncology Fellow, City of Hope National Medical Center (middle)
Clemens M. Schirmer, MD, PhD, Geisinger Health System (right) 

cfAs the world focused on the competitive athletes of the summer 2016 Olympic Games in Rio, we were inundated with stories of athletes overcoming adversities to achieve greatness. Concussions and the resultant side effects were central in many of these. While some of the athletes played contact sports, such as former NFL running back Jahiv Best, who transitioned to track and field, non-contact sports such as trampoline and cycling also impacted the athletes. Not surprisingly, a focus on concussions and post-concussive injury appears to be trending among former Olympic athletes as well. The soccer icon Brandi Chastain, who ripped off her shirt to celebrate the 1999 win of the Women’s World Cup, has decided to donate her brain posthumously to further the understanding of the potential neurodegenerative processes occurring from concussive injury among soccer players. Our co-author, Analiz Rodriguez, not necessarily famous for her middle school soccer plays, remembers falling backward during a game after making contact with another player. She blacked out for several minutes, and then after a short break was allowed back into the game. Nowadays, this immediate return to play would not be allowed due to increased concussion awareness and strict guidelines, which were created following concerns about long-term resultant neurologic deficits. The importance of this topic led Neurosurgery Blog to launch a concussion awareness campaign to put the spotlight on key issues surrounding traumatic brain injury (TBI). In the classic spirit of medical education, this grand rounds presentation gives a sweeping overview of the current state of #ConcussionFacts on this issue in the greater blogosphere.

What is a concussion?

Historically described as “punch drunk” or “seeing stars,” concussions are a type of mild traumatic brain injury usually caused by a blow to the head and may or may not cause a loss of consciousness.  Concussions can result in a wide range of symptoms including:

  • Headache
  • Dizziness
  • Confusion
  • Amnesia
  • Blurred vision
  • Double vision
  • Nausea

These symptoms can occur with varying combinations and degrees of severity making a definitive diagnosis difficult. Neurocognitive tests, like the immediate post-concussion assessment and cognitive test, or ImPACT,  have been developed to assess both children and adults for concussion. There are efforts underway to ensure this score is calculated for every TBI presenting to hospitals by integrating a function into the medical record. It remains to be seen whether this score can help improve our care for patients with concussion, but as a first step, it at least allows an objective measurement of what we are discussing.

Concussion and Sports

Concussions have garnered significant media attention, particularly focused on the association with sports, especially football. Here are some important sports #ConcussionFacts:

  • 2 million sports-related concussions occur in the United States, according to the Centers for Disease Control and Prevention (CDC);
  • Equestrian events carry the highest risk of concussion for athletes; and
  • Martial arts and diving are in the top five sports with a propensity for sustaining a concussion.

However, given the popularity in American culture, football remains the most covered sport in relation to concussions. As concussions can occur during youth athletics, concussion safety laws are now present in every state. Guidelines urge that return to play after concussion be assessed on an individual basis with more conservative measures for children and teens. Re-injury through repeated concussions can result in long-term deficits. The Sports Concussion Institute has developed return to play protocols to help guide when and how it’s appropriate to reintroduce someone to sports play.

Professional sports have widely divergent guidelines on return to play that are sometimes enforced with variable diligence. At the World Cup Final in 2014, German soccer player Christoph Kramer continued to play for 14 minutes after obviously sustaining a concussion. Subsequently, Fédération Internationale de Football Association’s (FIFA) rules on return to play came under scrutiny. Alternatively, when British judo champion, Kelly Edwards sustained a concussion in February 2016, she was mandated to take six months off and therefore had to forego the Rio Olympics.

Less appreciated is the fact that concussions also occur in women’s sports. A recent study indicates that in high school, young women are 1.5 times more likely to sustain a concussion in comparison to young men. In March 2016, Pink Concussions and Georgetown University co-hosted the International Summit on Female Concussion and TBI.  Women who are victims of domestic violence can also suffer repeated concussions.

Chronic Traumatic Encephalopathy

Repetitive traumatic brain injury including concussions may lead to chronic traumatic encephalopathy (CTE). Concussion, a 2015 movie which features actor Will Smith who played the scientist that discovered CTE after studying the postmortem brains of professional football players who had exhibited aggressive, suicidal or dementia-like behavior before their death. The conclusion of the movie, as well as the beliefs of many in the science world, is that CTE is a neurodegenerative disease and symptoms reveal themselves later in life, many years after participation in sports. CTE symptoms include:

  • Personality changes;
  • Suicidal potential;
  • Trouble thinking clearly;
  • Impaired memory; and
  • Problems with balance.

Bubba Smith, an NFL defensive end and actor, was one of several players found to have CTE after donating his brain to a research bank. Early athletes felt to have suffered CTE and its consequences, have motivated many current players to pledge to donate their brains for research (such as Brandi Chastain) to elucidate the cause of CTE further.


Our armed forces have significant interests in understanding concussions and CTE. Of note, 85 percent of concussions in the military occur during training, sports or vehicle accidents, rather than combat. More than a quarter million service members sustained a TBI from 2000 to 2012 during combat in Iraq and Afghanistan. The majority of these injuries were concussions from being struck, falling, or affected by a nearby blast or explosion. The military has developed guidelines for return to duty following concussions since it is believed that the ramifications of a concussive injury on a stressed brain (e.g. fatigue, anxiety, etc.) are more severe than those of concussive injury among most athletes. The guidelines are similar in that progressive activity is allowed in a step-wise fashion until being allowed back to active duty. For those veterans suffering more severe post-concussive injury, they are eligible for up to 100 percent of disability compensation.

Health Care Policy

In the landscape of health care policy, influential stakeholders and interest groups have often driven highly focused efforts within the overarching issue. A few notable efforts:

The internet and social media are abuzz on the topic on concussion, some useful but also much incorrect and inflammatory. To this end, Neurosurgery Blog has made a point to focus on #ConcussionFacts as we are at a crossroads in our understanding of and interventions for patients with concussions. There is increasing awareness, and interest, which is great. Technical capability will increasingly enable measurements and tracking of these patients and hopefully allow us to find a solution for this burgeoning problem with its huge impact! Neurosurgeons will continue to lead the way in all aspects of this public health concern.

Editor’s Note: We encourage everyone to join the conversation online by using the hashtag #ConcussionFacts.

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